Antipsychotic of choice in Alcohol Withdrawal

Hi Friends.

I saw this patient today and requesting your valuable thoughts and inputs.

Pt is in mid 40s, presented to Psychiatry emergency requesting detoxification from Alcohol (drinking daily heavily for last 3 months). Pt stopped Alcohol ~4 days ago (cold turkey) and presented to emergency in DTs (Delerium Tremens). Pt had a seizure and finally was intubated for airway protection. Pt is on Loraepam drip (7mg/hr) now and is also getting Haloperidol 5mg IV Q4hr since then (for agitation?). Today pt had an episode of generalized body stiffness with eye ball rolling backwards. Most likely a dystonic reaction from Haloperidol Vs Seizure. Haloperidol is discontinued and EEG is ordered. Will follow up for results tomorrow.

My question is: Which antipsychotic is preferred in patient with Alcohol withdrawal?
I know that typical antipsychotics are known to lower seizure threshold.
I am hesitant to start Quetiapine, as pt is very much sedated and primary team had problems with extubation (gets agitated with extubation procedure everytime).

Any inputs will be highly appreciated.

Thanks

I am not aware of antipsychotics having efficacy/safety data for agitation in alcohol withdrawal delirium. I would consider if it is possible that he is now delirious not due to alcohol withdrawal but due to over-medication with ativan. If that is the case and seizures have been ruled out, you could try giving a push of flumazenil.

If he has multiple signs of alcohol withdrawal and you feel this is truly a refractory alcohol withdrawal delirium, I would consider switching his ativan to diazepam and then increasing until sedated. Jose Maldonado recommends valproic acid being added for alcohol withdrawal delirium due to its glutamate blockade. That is also an option although there is not much published evidence for it's efficacy as far as I am aware.

I can post some references for this stuff if you want.

Good luck!

Thanks for this recommendations.
I like the conversion of Ativan to Diazepam.

Based on PubMed search following atypical antipsychotics are effective in alcohol withdrawal patients (studies done in rats).
Effectiveness rank of the used atypical antipsychotics was as follows: risperidone = quetiapine > ziprasidone > klozapine > olanzapine.
Source: Alcohol Alcohol. 2012 Jan-Feb;47(1):33-41

Also my supervisor attending gave me this interesting article on Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU.
Source: Rayner et al. Annals of Intensive Care 2012, 2:12

Records from a 23-bed mixed medical-surgical ICU were abstracted from November 2008 to November 2010 for patients who received dexmedetomidine for alcohol withdrawal.
The main analysis compared alcohol withdrawal severity scores and medication doses for 24 h before dexmedetomidine therapy with values during the first 24 h of dexmedetomidine therapy.

Results: There was a 61.5% reduction in benzodiazepine dosing after initiation of dexmedetomidine and a 21.1% reduction in alcohol withdrawal severity score. Patients experienced less tachycardia and systolic hypertension following dexmedetomidine initiation. One patient out of 20 required intubation. A serious adverse effect occurred in one patient, in whom dexmedetomidine was discontinued for two
9-second asystolic pauses noted on telemetry.

Conclusions: This observational study suggests that dexmedetomidine therapy for severe alcohol withdrawal is associated with substantially reduced benzodiazepine dosing, a decrease in alcohol withdrawal scoring and blunted hyperadrenergic cardiovascular response to ethanol abstinence.